Lymphoid morphology, hyperviscosity and extensive immunoglobulin deposits in myeloma

[摘要] A 64-year male presented with epistaxis and shortness of breath. Hehad haemoglobin of 92 g/L with normal white cell and platelet counts,IgGλ paraprotein of 45.2 g/L and normal creatinine and calcium levels.A blood film showed macroscopically visible immunoglobulin deposits,rouleaux formation and atypical lymphoid cells (Figure 1A: 20× objective; B: 50× objective; MGG stain). Plasma exchange led to rapidimprovement in symptoms. Bone marrow (Figure 1C: H&E, 40× objective; D: Giemsa, 40×objective) showed a 90% infiltrate of mononuclearcells, many with central nuclei and ‘clock-face’ nuclear morphology butsmall to medium amount of cytoplasm and general lack of perinuclearhalo. The flow cytometric immunophenotype of the population wasCD45–, CD19–, CD38+, CD56 bright and CD27–. Immunohistochemistry showed CD3–, CD5–, CD20–, CD79a–, CD138+, CD38+,MUM1+,CCND1–, CD56–, BCL2–, BCL6–, CD21–, CD23–, CD10–, μ heavychains –, γ heavy chain weak + and λ light chain restricted mononuclearinfiltrate. Fluorescence in situ hybridization showed t(4;14) and gainof CKS1B (1q21). Whole body magnetic resonance imaging revealed adiffuse low bone marrow T1 signal but no focal bone lesions. A diagnosis of plasma cell myeloma was made, and the patient was initiatedon bortezomib, thalidomide and dexamethason and went on to have anautologous stem cell transplant.